ORIGINAL ARTICLE
Colostomy for Perianal Sepsis With Ecthyma Gangrenosum in Immunocompromised Children Raphael N. Vuille-dit-Bille, MD, PhD,*w Christoph Berger, MD,wz Martin Meuli, MD,*w and Michael A. Grotzer, MDwy
Background: Perianal sepsis with ecthyma gangrenosum is a severe and potentially mutilating complication in immunocompromised children. Therapies include antimicrobial treatment, incision and drainage, generous tissue debridement, and skin transplantation. Procedure: We describe 3 children with acute lymphoblastic leukemia having sepsis with Pseudomonas aeruginosa in febrile neutropenia and severe perianal infections treated relatively early with a protective colostomy. Indications for colostomy were nonhealing wounds, and ceaseless pain. Results: All patients showed a rapid reduction of pain. Complete wound healing was seen in 2 patients, and considerable pain reduction and increased quality of life were seen in a third patient during palliative care.
Temporary colostomy may be used to keep stool out of the area of the colon and skin that is inflamed, infected, diseased, or newly operated on—this allows healing to take place. However, to the best of our knowledge, this approach has been reported so far in only 2 case series of perianal sepsis in immunocompromised children.1,4 Whether to perform a diverting colostomy is controversial, and evidence concerning indication and appropriate timing for local surgery as well as for colostomy type is lacking. The aim of the present study was to analyze the outcome after performing a diversion colostomy in 3 immunocompromised children with perianal sepsis and ecthyma gangrenosum (EG) as well as to review the literature.
Conclusions: These results suggest that a protective colostomy should be considered early in the management of immunocompromised children with ecthyma gangrenosum. Key Words: colostomy, immunodeficiency, leukemia, children, Pseudomonas aeruginosa, ecthyma gangrenosum, perianal sepsis
(J Pediatr Hematol Oncol 2016;38:53–57)
P
erianal sepsis is a life-threatening and potentially mutilating complication in patients with acute leukemia and other malignancies, which occurs either at the onset of disease or as an adverse effect of chemotherapy.1 Neutropenia represents a significant prognostic factor for infections in immunocompromised patients2 and for perianal sepsis in particular. The gram-negative bacterium Pseudomonas aeruginosa (PSA) is a common pathogen that may cause severe opportunistic infections invading the skin, the subcutaneous fat layer, as well as mucus membranes of immunocompromised children. The perianal region and the axilla are particularly prone to pseudomonas-related skin infections.3 Skin lesions at the perianal region may have serious consequences, including skin and soft-tissue necrosis including the sphincter apparatus. The latter may lead to lifelong incontinence. Treatment approaches include antimicrobial therapy, incision, vigorous tissue debridement, and skin transplantations.4
Received for publication October 30, 2014; accepted January 29, 2015. From the *Department of Pediatric Surgery; zDivision of Infectious Diseases and Hospital Epidemiology; yDivision of Oncology; and wChildren’s Research Centre, University Children’s Hospital of Zurich, Zurich, Switzerland. The authors declare no conflict of interest. Reprints: Michael A. Grotzer, MD, University Children’s Hospital, Steinwiesstrasse 75, Zurich CH-8032, Switzerland (e-mail: michael. [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Hematol Oncol
PATIENTS AND METHODS We describe 3 male patients aged 3.3 to 4.8 years with acute lymphoblastic leukemia suffering from PSA sepsis, febrile neutropenia, and severe perianal, ulcerative infections treated with a protective colostomy between January 2011 and December 2013 at the University Children’s Hospital of Zurich, Switzerland (Table 1). All patients had neutropenia with an absolute neutrophil count
Colostomy for Perianal Sepsis With Ecthyma Gangrenosum in Immunocompromised Children Raphael N. Vuille-dit-Bille, MD, PhD,*w Christoph Berger, MD,wz Martin Meuli, MD,*w and Michael A. Grotzer, MDwy
Background: Perianal sepsis with ecthyma gangrenosum is a severe and potentially mutilating complication in immunocompromised children. Therapies include antimicrobial treatment, incision and drainage, generous tissue debridement, and skin transplantation. Procedure: We describe 3 children with acute lymphoblastic leukemia having sepsis with Pseudomonas aeruginosa in febrile neutropenia and severe perianal infections treated relatively early with a protective colostomy. Indications for colostomy were nonhealing wounds, and ceaseless pain. Results: All patients showed a rapid reduction of pain. Complete wound healing was seen in 2 patients, and considerable pain reduction and increased quality of life were seen in a third patient during palliative care.
Temporary colostomy may be used to keep stool out of the area of the colon and skin that is inflamed, infected, diseased, or newly operated on—this allows healing to take place. However, to the best of our knowledge, this approach has been reported so far in only 2 case series of perianal sepsis in immunocompromised children.1,4 Whether to perform a diverting colostomy is controversial, and evidence concerning indication and appropriate timing for local surgery as well as for colostomy type is lacking. The aim of the present study was to analyze the outcome after performing a diversion colostomy in 3 immunocompromised children with perianal sepsis and ecthyma gangrenosum (EG) as well as to review the literature.
Conclusions: These results suggest that a protective colostomy should be considered early in the management of immunocompromised children with ecthyma gangrenosum. Key Words: colostomy, immunodeficiency, leukemia, children, Pseudomonas aeruginosa, ecthyma gangrenosum, perianal sepsis
(J Pediatr Hematol Oncol 2016;38:53–57)
P
erianal sepsis is a life-threatening and potentially mutilating complication in patients with acute leukemia and other malignancies, which occurs either at the onset of disease or as an adverse effect of chemotherapy.1 Neutropenia represents a significant prognostic factor for infections in immunocompromised patients2 and for perianal sepsis in particular. The gram-negative bacterium Pseudomonas aeruginosa (PSA) is a common pathogen that may cause severe opportunistic infections invading the skin, the subcutaneous fat layer, as well as mucus membranes of immunocompromised children. The perianal region and the axilla are particularly prone to pseudomonas-related skin infections.3 Skin lesions at the perianal region may have serious consequences, including skin and soft-tissue necrosis including the sphincter apparatus. The latter may lead to lifelong incontinence. Treatment approaches include antimicrobial therapy, incision, vigorous tissue debridement, and skin transplantations.4
Received for publication October 30, 2014; accepted January 29, 2015. From the *Department of Pediatric Surgery; zDivision of Infectious Diseases and Hospital Epidemiology; yDivision of Oncology; and wChildren’s Research Centre, University Children’s Hospital of Zurich, Zurich, Switzerland. The authors declare no conflict of interest. Reprints: Michael A. Grotzer, MD, University Children’s Hospital, Steinwiesstrasse 75, Zurich CH-8032, Switzerland (e-mail: michael. [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Hematol Oncol
PATIENTS AND METHODS We describe 3 male patients aged 3.3 to 4.8 years with acute lymphoblastic leukemia suffering from PSA sepsis, febrile neutropenia, and severe perianal, ulcerative infections treated with a protective colostomy between January 2011 and December 2013 at the University Children’s Hospital of Zurich, Switzerland (Table 1). All patients had neutropenia with an absolute neutrophil count
